Suicidal behavior and prevention strategies from teachers' perspective

ABSTRACT

Objective

To analyze the knowledge on suicidal behavior and prevention strategies adopted by elementary school teachers.

Method

A qualitative study, supported by action research, carried out in a public school in the city of Teresina, Piauí, Brazil. Nine elementary school teachers took part. Three meetings, a negotiation meeting and two thematic seminars were held. The speeches were submitted to thematic analysis.

Results

Teachers' knowledge about suicidal behavior involves the identification of the warning signs, with self-mutilation being the most recurrent suicidal attitude. As strategies, they pointed out the need to avoid the risk of identifying the student at risk, observation, dialog, monitoring and using the support networks. The challenges listed by the teachers were the following: being unable to identify and associate the warning signs with the suicidal behavior, difficulty in approaching the student in crisis, lack of mental health staff in schools, and transversal themes in the school curricula.

Conclusion and implications for the practice

The need for actions aimed at the training of these professionals is observed, in view of their privileged position for the promotion of food environments, as well as for the prevention and identification of adolescents at risk, with appropriate management and shared referral to the health services.

Keywords:
Suicidal Ideation; Social Vulnerability; Knowledge; Adolescent; School Teachers

RESUMO

Objetivo

Analisar conhecimentos sobre comportamento suicida e estratégias de prevenção adotadas por professores do ensino fundamental.

Método

Estudo qualitativo, apoiado na pesquisa-ação, realizado em escola pública do município de Teresina, Piauí, Brasil. Participaram nove professores de ensino fundamental. Realizaram-se três encontros, uma reunião de negociação e dois seminários temáticos. Os discursos foram submetidos à análise temática.

Resultados

O conhecimento dos professores acerca do comportamento suicida envolveu identificação dos sinais de alerta, tendo a automutilação como atitude suicida mais recorrente. Como estratégias apontaram a necessidade de prevenção por meio da identificação do aluno em risco, da observação, do diálogo, do monitoramento e utilização de redes de apoio. Os desafios elencados pelos professores foram a inabilidade na identificação e associação dos sinais de alerta com o comportamento suicida, a dificuldade na abordagem do aluno em crise, a ausência de equipe de saúde mental nas escolas e de temas transversais nos currículos escolares.

Conclusão e implicações para a prática

Observa-se a necessidade de ações voltadas para a capacitação desses profissionais, tendo em vista sua posição privilegiada para promoção de ambientes saudáveis, bem como para prevenção e identificação dos adolescentes em risco, com manejo adequado e encaminhamento compartilhado aos serviços de saúde.

Palavras-chave:
Ideação Suicida; Vulnerabilidade Social; Conhecimento; Adolescente; Professores Escolares

RESUMEN

Objetivo

Analizar el conocimiento sobre el comportamiento suicida y las estrategias de prevención adoptadas por los maestros de la escuela primaria.

Método

Estudio cualitativo, apoyado por una investigación de acción, realizado en una escuela pública en la ciudad de Teresina, Piauí, Brasil. Participaron nueve maestros de la primaria. Se celebraron tres encuentros: una reunión de negociación y dos seminarios temáticos. Se sometieron los discursos al análisis temático.

Resultados

El conocimiento de los docentes sobre el comportamiento suicida implica identificar señales de alerta, siendo la automutilación la actitud suicida más recurrente. Como estrategias, señalaron la necesidad de prevención, a través de la identificación del estudiante en riesgo, de la observación, del diálogo, de un seguimiento y del uso de redes de apoyo. Los desafíos enumerados por los maestros fueron la incapacidad de identificar y asociar señales de alerta con la conducta suicida, dificultad para acercarse al estudiante en crisis, falta de personal de la salud mental en las escuelas y de temas transversales en los planes de estudio escolares.

Conclusión e implicaciones para la práctica

Se observa la necesidad de acciones dirigidas a la capacitación de estos profesionales, en vista de su posición privilegiada para promover ambientes sanos, así como para prevenir e identificar adolescentes en riesgo, con un manejo adecuado y derivación compartida entre la escuela y los servicios de salud.

Palabras clave:
Ideación Suicida; Vulnerabilidad Social Conocimiento; Adolescente; Maestros

INTRODUCTION

Suicidal behavior is any act by which the individuals harm themselves, regardless of the degree of lethal intent and the true reason for that act.¹ It is a complex phenomenon that has no single cause, but which is influenced by several factors that act in multiple dimensions: individual, family, community, and social.² Its spectrum ranges from ideation, which can be communicated by verbal and non-verbal means, to planning, suicide attempt and, finally, suicide.³

National and international data have identified a high prevalence of this behavior in adolescents.^4,5 The increased incidence in adolescence can be explained by being a phase marked by conflicts, changes, physical and sociocultural transformations, which favor levels of anxiety and depression, the main risk factors for suicidal behavior.³

A number of studies indicate that adolescents who attempted or committed suicide showed early warning signs. They tended to talk about suicide, having problems sleeping and eating, getting away from friends, donating valuables, losing interest in their personal appearance, using alcohol and drugs, and taking unnecessary risks.^6,7

In this perspective, identifying adolescents at risk is the main means for developing coping strategies and for preventing suicidal behavior in this age group. Due to the closer contact with families, the Family Health Strategy (FHS) together with schools, through the Health in the School Program (SHP), can become spaces for the prevention of suicidal behavior among adolescents, with the support of the teachers.

It is noteworthy that teachers are in a strategic position within the school setting to act as providers of the prevention of suicidal behavior, through the use of prevention strategies that involve resilience interventions, promotion of a culture of peace, identification of the warning signs, in addition to being able to provide first-line support to adolescents, as they are in continuous and daily contact with students and are a link among the health services.⁸

However, there is silence on the theme and/or minimization of the problem, both in the school and health contexts. There is evidence of teachers' unpreparedness, ignorance and insecurity in approaching and managing adolescents at risk, which confirms the weakness of preventing this problem in the school context.^6,9

As a result, only 1.3% of the young people report their thoughts to the professional teacher, because they feel insecure, because of fear of judgment and because they believe that they are not prepared to deal with the situation.¹⁰ Thus, taking into account that less than a third of the adolescents seek professional help or medical treatment,¹¹ there is a need for training these professionals on the subject, aiming to increasing knowledge and confidence in the approach and management of the adolescents, of the places and forms for the available support, allowing for the timely monitoring and identification of the young people.

Thus, considering the complexity of the problem and the existence of a portion of the society under suicidal behavior risk, it is necessary, therefore, that the school may start to deal with this issue as something real, existing and present in the students' daily life, in the seek for breaking the complicity of the silence that leads to the denial or the minimization of the suicidal behavior.¹²

Therefore, this study aims to analyze knowledge about suicidal behavior and prevention strategies adopted by elementary school teachers.

METHOD

A qualitative study, supported by action-research, being a type of empirically based social research that is conceived and carried out in close association with an action or the resolution of a collective problem and in which the researchers and participants representing the situation or problem are involved in a cooperative or participatory manner.¹³

In relation to its planning, action-research is flexible, it does not follow a series of strictly ordered phases. In this study, it was chosen to adhere to the following operational phases: introductory or negotiation; development (thematic seminars); data mapping and categorizing; and result submission.¹³

It was held at a public school in Teresina, Piauí, Brazil, which has an agreement with the SHP and works in the education of adolescents.

The research participants were nine elementary school teachers, from the afternoon shift, from classes from the sixth to the ninth grade, which corresponds to the age groups from 11 to 15 years old. The shift was chosen because it had a higher concentration of teachers who worked in the education of adolescents.

The inclusion criteria were defined as following: teachers of both genders and who had at least one year of teaching experience. Those on vacation or leave from their work activities during the period of data collection were excluded.

Three meetings were held in the school's meeting room, as it is easily accessible to teachers and because it is located in the work environment, which facilitated attendance.

In the first meeting (negotiation meeting), the dates and times of the meetings were chosen by the participants, in line with the school management, so that it would not cause any harm to the school schedules. At this moment, the research objectives, the methodological strategy, the study team and the reading and signing of the Free and Informed Consent Form (FICF) were presented. A duration of two and a half hours has been proposed for each seminar, and the schedule may be extended, as necessary. An identification badge with the letter P (P1, P2, P3...) was given to each teacher, in order to ensure information’s confidentiality.

The first thematic seminar was held in the second meeting, conducted by the following guiding question: “What knowledge do you have about suicidal behavior in the school context?” For its conduct, the dynamics of creativity and sensitivity called “Free to create” were used. The objective of the dynamic is to bring participants closer to the theme, allowing for the exercise of critical and reflective sense during the process of artistic creation, through freedom of thought, incited through creativity.¹⁴

The second thematic seminar was held at the third meeting. The following guiding question was used for its conduction: “What do you do to detect and/or prevent suicidal behavior?” The “Cut and paste” dynamic was chosen, in which clippings from magazines are used to prepare artistic productions.

After creating the artistic representations, which were conducted through the aforementioned guiding questions, the participants socialized the material prepared by the group – a moment of verbal expression of their knowledge and practices about the suicidal behavior.

The seminars were recorded in minutes. The speeches from the discussions and triggering questions were recorded in an IoS application and later on transcribed for analysis. At the end of each dynamic, the participants returned formal knowledge through mini expositions. The speeches were submitted to thematic analysis,¹⁵ carried out in three stages: exploratory, fieldwork, and analysis/treatment of empirical and documentary material.

The ethical aspects of Resolution No. 466/12 of the National Health Council were observed. The study was approved, on April 9^th, 2019 by the Research Ethics Committee of the Federal University of Piauí, according to Opinion No. 3,252,786.

RESULTS

Of the nine teachers who participated in the study, five were women and four men, aged 24 to 39 years old. Regarding employment, eight were statutory and only one worked under a temporary contract. Six were also teaching at another educational institution. Graduation time ranged from two to fifteen years. As for training, seven had some specialization and another two were only undergraduates.

Two categories emerged from data analysis:

Teachers' knowledge about suicidal behavior and prevention strategies in the school context

Teachers' knowledge about suicidal behavior is referred to through the student's observation of sadness, isolation, and family problems, resulting in sudden changes in the classroom. In the speech of teachers, self-mutilation was recurrent as the main suicidal attitude in the school context.

I made a little guy with his head down on the table, that sometimes we see these sad students, for no reason. Sad, crestfallen, isolated and such. I also made a girl cutting herself with a razor, which we see a lot today, a self-mutilating kid. (P1)

I drew an isolated little boy. Because I consider isolation to be a suicidal behavior. Isolated, sad children have to be watched. (P2)

What I observed of suicidal behavior in the classroom was a student from last year, a teenager, self-mutilating, cutting herself with a stylus, crying a lot. (P4)

I also talked about self-mutilation, because it was well marked on me last year, a student started to self-harm inside the classroom and it shocked me a lot, it marked me, she cut herself, I screamed, some people saw and screamed. (P6)

I drew a sad little boy, sitting, questioning himself: Why am I sad? Why am I alone in the world? Why am I thinking of taking my own life? Thus, I consider sadness and isolation suicidal behaviors. (P8)

Teachers state that family relationships interfere with changes in adolescent behavior in the school setting and may be related to suicidal behavior.

Family problems interfere a lot in the teenager's behavior. (P1)

I have posted images of family and social abandonment, as well as images of domestic violence and may also include sexual. Last year, I had a student who was having a lot of family problems at home and she was also very aggressive in the last days in the classroom, withdrawn, sad. (P4)

Most students here have family problems, they have emotional problems. (P6)

Regarding the knowledge about preventing this behavior in the school context, support networks were mentioned as bonds of friendship, professional monitoring and the importance of the family and, in particular, of the parents as collaborators in this process.

I put here two images representing friendship, because I imagine that one of the things that can help a person who is in this moment of depression with a tendency, perhaps, to commit suicide is to have friends, to receive affection, that kind of thing only helps. (P1)

I would guide professional help, I also imagine that schools should have a social worker and psychologist working at the school. At the very least, it would guide the teenager to seek help. (P2)

I put another thing that is the family issue, it is important to have a good family base, parents present in the student's life. (P7)

I even talk to them, if you don't want to open up to me, look for your parents, if you don't want to open up to your parents, try to see the direction, look for someone and talk, you don't have to go through this problem alone. Seeking professional help, integration, building friendships to talk and share problems. (P9)

It stands out as a strategy mentioned by the teachers in the prevention of suicidal behavior, the teacher-student approach to create bond and links of trust.

As a teacher of a student at risk for suicide I can help by approaching the student, trying to bring other students closer in order to welcome. (P1)

So, I always try dialog with the student, I always try to do that, I always tried and now even more, to show reality not in a sudden way, but also without touching my head, trying to show that reality, showing no, they already know, work or talk about it [...]. (P7)

Teachers consider bullying identification and awareness in the classroom as a way for preventing suicidal behavior in the school context.

It is important to note bullying in the classroom and make students aware of its effects and consequences for others. (P1)

I have a student who stutters and the boys are nicknaming him with different nicknames. There was a week when he was very sad and I realized it, the math teacher noticed and we both went to the direction and talked. Then, the boys who nicknamed him were identified and the necessary measures were taken. (P5)

Challenges for preventing suicidal behavior in the school context

The following can be mentioned among the challenges for preventing suicidal behavior in schools: the difficulty of teachers in identifying and associating the warning signs with suicidal behavior, the absence of a mental health team in schools, and the non-discussion of transversal themes in the school context.

The lack of knowledge on the subject makes it difficult to identify the signs and prevent. (P4)

I couldn't associate the warning signs with suicide, I had a student who had attempted suicide, after talking to his mother and someone else, I knew, I could see that there was something strange, but I would never take that side, I confess that I never took that side of suicide. (P7)

From the moment that I’ve observed that the students are behaving strangely, I find it difficult to reach them, to talk to them, to ask what they have and still there is the resistance on the part of the student to open up [...]. (P9)

Teachers see the importance of the mental health team at the school as a way to help promote mental health and prevent suicidal behavior. Another challenge mentioned for this prevention is the lack of discussion of transversal themes in schools. Teachers understand the relevance of the interdisciplinary approach to the theme as an effective prevention form.

Schools should have professionals such as a social worker, psychologist, nurse in the school, but they don't! I believe it would help a lot. (P1)

The limitations in the case of my discipline which is Mathematics, is that it is not discussed much, something that should be a general topic. (P2)

It would be very helpful to have a permanent professional at the school, like a psychologist, psycho-pedagogue, someone providing support in the mental field. (P3)

The point is that there should be an interdisciplinary project in the school addressing the various areas and working hard with the theme. (P4)

DISCUSSION

It was observed that the knowledge of the teachers on suicidal behavior is guided by the identification of the warning signs in the classroom, such as isolation, sadness, and conflicting family relationships. However, there is a lack of knowledge on the forms of expression for this behavior.

Social isolation, sadness, and family problems are considered risk factors for suicide.^1,7 Several studies have identified a greater predominance of moderate to severe suicidal ideation in adolescents of negative mood, sad, with a tendency to isolation, and who had vulnerability in family cohesion.^16,17

A repetition and generalization of the word sadness among adolescents becomes evident in the teachers' discourse, which leads us to reflect on whether it would be only a momentary aspect due to an isolated factor or an undiagnosed depressive condition.

Depression is of a different nature from the sadness and discouragement that we naturally feel in some moments of life. Several research studies show a direct relationship between depression and suicidal behavior.^9,18 Therefore, differentiating them becomes essential for better monitoring, treatment, and prevention.

In the teachers’ view, family problems were related to suicidal behavior and were expressed through family instability, distancing of the parents from their children, lack of communication, and sexual and domestic violence.

Lack of communication with the parents, dissociated parenting relationships, childhood abuse, and domestic violence are risk factors for self-harm and future suicide attempts.^19,20 In contrast, having a positive parent-child connection and spending time together are protective factors.²⁰

Parents play an essential role in the well-being and mental health of adolescents. It is essential to create a link between school and family, in order to overcome barriers and challenges in the face of suicidal behavior. Among the challenges is the difficulty of contact with parents during the crisis, the lack of time for school programs, and the lack of perception or minimization of the problem.²¹

Despite the difficulties in achieving this harmonious relationship, the importance of parental participation in this process is evident, in order to promote a family environment of protection for adolescents, during periods of psychological instability.²²

These periods of instability can develop into suicidal behavior. Self-mutilation was the most recurrent form of expression of suicidal behavior from teachers’ perspective. Currently, it is one of the main public health concerns and self-cutting is the most common method of self-harm.^23,24 Several studies associate self-harm in adolescents as a strong predictor of future suicide attempts^25,26 relating self-harm to early adolescence and attempts at a later stage.²⁵

As for the prevention of suicidal behavior in the school context, the teachers mentioned the need for early identification and diagnosis of the student in crisis, through the student's approach, dialog, through informal conversations and the help of support networks such as friendship, professional help and the family.

Suicidal desire causes changes in daily activities, which can be observed and analyzed by people close to the individual, which allows them to offer the necessary assistance in advance in risky situations.^6,27

However, it is important to consider that suicidal behavior is still treated as a taboo, a stigma in the school context, resulting in judgmental stances, both by teachers and by other students when observing behavior changes, which can be explained by ignorance, feeling impotence and fear, given the complexity to manage the situation safely and effectively.¹²

During the speech, friendship, family, and professional help were appointed with support networks. It is emphasized that social support promotes mental health and prevents mental problems, while the lack of it contributes to the increased incidence of suicidal behavior.²⁸

Working in a network, knowing the flows established in the health services, creating healthy alliances, connecting knowledge-action, seeking a new look at the subject in psychological distress in the intervention of the suicide crisis, which is not based only on their illness, their sequelae and their social ills, thinking about health actions from the perspective of prevention, promoting not only mental health, but viewing the individual in a holistic way, are ways to prevent suicidal behavior.²⁹

Still with regard to preventing suicidal behavior, teachers mentioned dialog and the teacher-student approach, in order to welcome and be a support for them, inside and outside the school. Another conduct is related to preventing bullying. However, what was observed is that there is a gap between the desired and reality since, in practice, there is only a transfer of responsibilities to higher hierarchical levels, in detriment to the prevention and awareness policies on the subject.

Bullying is defined as negative and intentional actions repeated for no apparent reason and can be carried out directly or indirectly. The direct actions include physical and verbal aggressions; the indirect actions happen through the spread of unpleasant and derogatory rumors, aiming at the disqualification and exclusion of the victim from his social group.³⁰ Being a victim of bullying is associated with several academic, social, emotional, and behavioral problems³¹ in addition to contributing to a higher incidence of self-injurious behavior.^32,33

Bearing in mind that the highest occurrence of bullying is in the school setting, it is up to the schools to act early, through the approach of transversal themes, stimulating reflection by teachers, about their teaching practices, establishing relationships with students and committing themselves to a healthier education, in which respect, solidarity and cooperation predominate.³¹

Although the teachers perceived changes in the behavior of the adolescents, they did not list them as triggering signals for suicide, which directly interferes with the intervention and the application of preventive measures, in view of the teachers' strategic position for the early identification of these behavioral changes, in addition to impairing the provision of first-line support to adolescents and shared referral, in a timely manner to specialized services. This result corroborates with other studies, which describe the ignorance of teachers about the warning signs and the need for training on the subject in the schools.^34,35

Therefore, the creation of policies aimed at the training and education of these professionals for identification, a correct approach of the student in crisis, and prevention of risk signals, as well as enabling them to deal with students' uncertainties and emotions after an incident, become essential for preventing suicidal behavior in the school context.

The absence of a mental health team in the schools was considered a challenge for the teachers. This demand is already a reality in other countries, which consider the integrated approach between educators and mental health professionals beneficial for the community, with school settings that promote health, more confident professionals to deal with adolescents in crisis situations and greater resolution capacity within the school environment.^34,35

Thus, the lack of mental health support services in schools brings with it the scarcity of strategies for the management of suicidal behavior on the part of teachers, which can be explained by fear, insecurity, denial, and ignorance, which causes them to refer the adolescents to specialized services as a way to get rid of the “problem”, which in turn causes the loss of opportunity for interventions within the school context and creating a bond with the adolescent at risk. Although referral to specialized services is understandable to ensure the most appropriate support, it can help students to no longer want to seek help in the school context, in addition to helping perpetuate the invisible nature of such behaviors.³⁶

Another challenge was the non-discussion of transversal themes in the school context. The non-insertion of the theme in the curriculum is seen by teachers as a difficulty for its prevention, and the incorporation of the theme in the school's pedagogical political project is suggested.

In Brazil, albeit in an incipient way, this inter-sectoriality between health and education in the field of mental health is materialized through the SHP, which works in defined territories, according to the area covered by the FHS and occurs through the interaction of these primary care health teams with education teams, in the planning, execution and monitoring of prevention, promotion, and evaluation of the students' health conditions.³⁷

The schools that adhere to the SHP must qualify their pedagogical political project to include new approaches and themes, and it is recommended that the health teams participate in the planning and execution of actions.³⁷ However, there is a gap between politics and reality, in which specific activities predominate, isolated and marked by the lack of sharing between the health and education sectors, which interferes in the quality of care and monitoring the students.

Thus, it is necessary to overcome this fragmentation and seek inter-sectoriality to understand the need for shared management and networking, with the inclusion of new approaches and a transversal perspective. In addition, of course, to a new look at the health-disease process in the school context, based on health promotion and prevention strategies.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

The teachers' knowledge on suicidal behavior involves identifying the warning signs, observed through sadness, isolation of the student, and family problems, with self-mutilation as the most recurrent suicidal attitude in the school context. They point out to the need for prevention, through the identification of the student at risk, observation, approximation, dialog, monitoring and help of support networks as bonds of friendship, professional, and family monitoring.

The challenges for implementing this behavior in the school context were the following: teachers' inability to identify the warning signs and associate them with suicidal behavior, difficulty in approaching the student in crisis, absence of a mental health team in the school context, and discussion of transversal themes in the school curricula.

The impact of this study for nursing is related to the need to improve the skill of this professional as a mediator between the two sectors, taking into account their strategic position and theoretical knowledge about networking. As a limitation, the small sample of participants is recognized, as well as it having been carried out in a specific geographical location.

Further studies are recommended in other settings and with other professionals from the school community, so that suicidal behavior may be perceived as something real in the daily lives of the adolescents, which requires trained teachers to prevent, identify, and cope with this set of problems.

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Edited by

ASSOCIATED EDITOR

Antonio José de Almeida Filho

Publication Dates

• Publication in this collection
  03 July 2020
• Date of issue
  2020

History

• Received
  03 Apr 2020
• Accepted
  08 May 2020